Fifty percent of participants presented late to HIV services. High primary and secondary care use was found prior to HIV diagnosis representing missed opportunities for earlier HIV diagnosis. Primary care in particular was extremely well utilized by this high-risk population; however HIV testing was not broached by the GP for 82.4% (145/176) of Africans who subsequently tested HIV positive. Medical attention was sought for wide-ranging reasons, often not obviously connected to underlying HIV status. Despite the population predominantly coming from countries of high HIV prevalence personal appreciation of risk was comparatively low and knowledge lacking as to the benefits of HIV testing. Whereas people testing HIV positive after a previous negative test reflects failure in prevention messages, people who had previously tested for HIV (37.1%) were less likely to present to HIV services late. Confidentiality concerns meant trust and disclosure of HIV status to GPs was low.
Since 2000 there has been a 179% increase in heterosexual men and women seen for HIV care in the UK, the majority of whom are African . High uptake of HIV testing [11,12] and primary care services  by African communities have been known for some time, and Sullivan et al.  reported that 17% of newly diagnosed HIV-positive patients had sought medical care with symptoms suggestive of HIV in the 12 months preceding diagnosis. There has, however, been no other studies that have specifically explored the missed opportunities for earlier HIV diagnosis among Africans within primary and secondary care settings.
Our study had some limitations. The study design meant only those people already accessing care were eligible. This could introduce selection bias, it is possible that this population may be more favourably disposed to and eligible for medical services than those not accessing services. The 17 people who were potentially eligible but died before being approached may have differed in their opportunities for earlier diagnosis in comparison with the sampled population. As all of these patients died of advanced HIV-related diseases, if any missed opportunity for earlier diagnosis did exist this reflects a real failing on the part of our health services. If no such opportunity had existed then we must ask ourselves why someone who was likely to have been unwell had not been or felt able to seek medical care earlier. Similarly of concern is the substantial proportion (15.4%) of potentially eligible patients who became lost to clinic follow up. These people may also differ in comparison with the sampled population. Although getting people into HIV services earlier is the first step to improving clinical outcomes, this will only be achieved if people find services acceptable and are able to continue to access them. The study was limited to London and so was unable to assess if people moving away from their communities, as in the asylum dispersal scheme , had any impact on opportunities for earlier diagnosis.
As data were collected retrospectively recall bias may have occurred, especially for those in whom prior accessing of health services was associated with their HIV diagnosis. Any effect of this is, however, likely to have been small given that participants were surveyed within 12 months of HIV diagnosis (the median time between diagnosis and questionnaire completion was only 3.5 months) and questions around healthcare were deliberately restricted to a relatively narrow time frame. Finally the term ‘African’ comprises an aggregation of heterogeneous population subgroups. Although data were collected to explore the ethnic, cultural and temporal diversities of this population the study may have lacked power to fully explore their influences on missed opportunities for earlier diagnosis of HIV infection.
Despite these limitations, our findings add substantially to our understanding of health-seeking behaviours of Africans living in the UK. Our data suggest that rather than having poor access to health services, as reported for many migrant groups, Africans report higher rates of primary and secondary care attendance and HIV testing than the general population (F. Burns and C. Mercer, pers. comm. 2007). That Africans continue to present to HIV services with advanced disease despite accessing health services prior to diagnosis suggests HIV is often missed as a differential diagnosis, or that clinicians are either reluctant to address HIV or are doing so ineffectively. Similarly, that many Africans test HIV positive after a previous negative test, suggests these HIV prevention opportunities are not being used effectively.
The age and country of origin of participants alone should guide health practitioners to the possibility of HIV infection irrespective of health status. Although some of the reasons for attending medical services may relate to HIV, many do not. Our findings suggest a proactive approach to HIV testing, as found in the antenatal setting, is required to minimize these missed opportunities for earlier diagnosis. A total of 37.1% of respondents reported a previous negative HIV test, and although the majority of these occurred in Africa, 32.5% had occurred in the UK. HIV infection risks are ongoing, with acquisition within the UK a real phenomenon for resident Africans. The continuing care relationship inherent in general practice provides an ideal context for ongoing HIV prevention messages. Similarly the majority of people came from countries with a high HIV prevalence but there was a comparatively low appreciation of personal risk, as reflected in the factors preventing earlier testing. Again primary care may be well placed to address these issues as it provides a setting for personalized and targeted health information. Advice from doctors, either primary or secondary care based, is influential with 40.2% primarily testing for HIV because of clinician recommendation.
Much of the failure to address the issue of HIV for this population may be the legacy of the HIV exceptionalism largely generated by HIV services over the past two decades. The whole process of HIV testing needs to be further normalized. Normalization refers to the process of treating HIV more like other infectious diseases for which early diagnosis is essential for appropriate therapeutic and preventive measures . It encapsulates the notion that all doctors should be confident and competent at HIV testing and diagnosis. It also still incorporates the need for confidentiality and informed consent. The Centres for Disease Control and Prevention (CDC) now recommends that HIV screening be performed routinely in all health-care settings for 13–64 year olds . GP's should be the first port of call for all health issues, including HIV. The ongoing care relationship provided by primary care services should lend itself to the provision of personalized ongoing HIV information and repeat screening opportunities. Work to address the concerns of service users around HIV and primary care is also required.
The National Strategy for Sexual Health and HIV  in 2001 set clear targets for HIV testing and reducing undiagnosed infection. In practice these recommendations have yet to be realized, probably because the low priority attributed to sexual health in most primary care trusts has resulted in lack of funds. Proposals to exclude overseas visitors from eligibility to free NHS primary medical service , designed to align primary care with hospital care, will further reduce opportunities for earlier diagnosis. A more positive approach would be to ensure that health services that are currently well utilized by this high-risk population have both the resources and incentives to effectively address HIV.
The key messages that are a result of the present study are listed here.
1. Late diagnosis of HIV increases HIV-associated morbidity and mortality and hinders prevention measures to limit onward transmission.
2. Africans in the UK access HIV services at a later stage of disease than non-Africans; missed opportunities for prevention messages and earlier HIV diagnosis within primary and secondary healthcare settings have not been fully identified for this population.
3. A total of 37.1% of newly diagnosed HIV-positive Africans had a previous negative HIV test, 32.5% of these within the UK.
4. Africans are accessing health services but clinicians are failing to use these opportunities effectively for preventive and diagnostic purposes with regard to HIV infection.
5. Primary care in particular is extremely well utilized by this high-risk population; however HIV testing was not broached for 82.4% of Africans who accessed GP services in the year prior to HIV diagnosis.
The authors would like to thank all those who participated in the study: C.M. Mercer and A. Copas for statistical support; the African HIV Research Forum steering committee; and staff at all participating centres: Archway Sexual Health Clinic: Denise Thorburn, Jo Baruah; Central Middlesex Hospital: Dr Gary Brook; Charing Cross Hospital: Dr John Wright, Dr Anil Rajkumar; Chelsea & Westminster Hospital: Dr Anton Pozniak; Homerton University Hospital: Nicky Hicky; Mortimer Market Centre: Dr Patrick French, Liz Kirkpatrick; Newham University Hospital: Cheryl Tawana; North Middlesex Hospital: Anele Waters, Fiona Young; St. Bartholomew's & the Royal London Hospitals: Are Isaksen; St. George's Hospital: Simone Ghosh, Ade Adebiyi; St. Mary's Hospital: Dr Harpal Lamba, Julie Fowler; University College Hospital: Dr Rob Miller, Peter McKenzie; Victoria Clinic for Sexual Health: Tony Kerley; Watford District General Hospital: Dr Pat Munday; Whittington Hospital: Patricia Whyte.
Contributors: F.B. helped design the study, was responsible for study coordination, data collection, statistical analysis and was the lead writer of this paper. A.J., J.N. and K.F. on participated in the design of this study and preparation of this manuscript. The SONHIA collaboration group were responsible for managing the study, data collection, and preparation of this manuscript. All authors have seen and approved the final version of this manuscript.
The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. The guarantor of the study is Dr Fiona Burns.
Members of the SONHIA Collaboration Group: M. Chikohora (North West London Hospitals NHS Trust, London), S. Manney (Barts and The London NHS Trust, London), L. Muromba (Homerton Hospital NHS Trust, London), N. Nwokolo (Chelsea and Westminster Healthcare NHS Trust, London), N. Panahmand (Camden Primary Care Trust, London), M. Slinn (West Herts Hospitals NHS Trust, London), and R. Stack (Chelsea and Westminster Healthcare NHS Trust, London).
Sponsorship: Dr Fiona Burns is supported by a Wellcome Training Fellowship (Grant 066866).
There are no conflicts of interest.
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Keywords:© 2008 Lippincott Williams & Wilkins, Inc.
Africans; healthcare access; HIV/AIDS; knowledge and attitudes; UK